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MALTREATMENT INVESTIGATION MEMORANDUM Minnesota Statutes, section 626.557, subdivision 1 states, “The legislature declares that the public policy of this state is to protect adults who, because of physical or mental disability or dependency on institutional services, are particularly vulnerable to maltreatment.”
License Number and Program Type: 1070504-H_CRS (Home and Community-Based Services-Community Residential Setting) 1070470-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: It was reported a staff person (SP) told a resident (R1) to rock the couch until a vulnerable adult (VA) fell off, and the SP had R2 “block” the VA from moving to another room which resulted in VA falling and scraping his/her knee. The SP also taunted the VA by called him/her “a big fucking baby” and an “ass whip.” Date of Incident(s): September 22, 2023 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 2, paragraph (b), clause (2); and subdivision 17, paragraph (a): Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information was obtained during a site visit conducted on October 27, 2023; from documentation at the facility and/or law enforcement (LE) records; and through six interviews conducted with the VA, a facility staff person (P1), facility supervisors (P2 and P3), the VA’s housemate (R2), and the SP. A former housemate (R1) moved out of the facility prior to the site visit and was not interviewed. Facility documentation showed the VA enjoyed shopping, gardening, and going out to eat. The VA was diagnosed with developmental disabilities, Down syndrome, and was nearsighted, however the VA chose to not wear glasses. The VA required staff supervision 24 hours day, and had difficulty with “impulse control, controlling target behaviors, and acting socially appropriate.” The VA’s Individual Abuse Prevention Plan stated the VA was susceptible to emotional/verbal abuse. The VA occasionally made comments to others, or about others in a negative manner, which might provoke teasing or verbal aggression. The VA’s Crisis Intervention stated the following: · If the VA exhibited aggressive behaviors, it was best to give him/her time. Staff persons would listen to the VA when s/he was ready to talk, and should not react immediately. · When the VA experienced unstable mental health s/he might engage in verbal aggression or make statements of self-harm. However, most of the time the VA went to his/her bedroom to think. Later, the VA would come out of his/her room and ask staff persons to talk in order to resolve the situation. · The VA might “act out” if s/he felt a housemate was getting more attention than him/herself. · The VA viewed redirection techniques that placed limits on the VA as an imposition on his/her personal authority to make decisions. Staff persons should redirect the VA by offering the VA one or two tasks/activities to allow the VA to feel like s/he was making a decision, rather than being told what to do. The redirection should be completed 1:1, and not in front of other persons. · Staff persons should avoid “highly confrontational and pressured intervention” when the VA was in crisis. Staff person should not “come off as bossy towards” the VA. LE records provided the following information: · LE was contacted on September 22, 2023, at 11:51 p.m., after the VA threatened to stab the SP regarding an issue with a television. · LE interacted with the VA on September 23, 2023, at 12:50 a.m. The VA was upset and told LE the SP and R1 were “being mean” and “picking on” the VA. LE noted there were no signs of a disturbance in the residence, and nothing was broken in the VA’s room. The VA said R2 had thrown him/her down to the floor and the VA had a “skinned knee.” The SP told LE s/he did not know how the VA’s knee was injured. · The SP made multiple requests that LE remove the VA from the facility for the night, but LE did not have a reason to remove the VA. The VA declined going to a medical facility for the injury to his/her knee. · P1 went to the facility and did not believe there was concern for further issues. The VA agreed to stay in his/her room and away from housemates for the rest of the night. P2 provided text messages from the SP dated September 22, and 23, 2023: · On September 22, 2023, at 11:08 p.m.: o The SP texted, “[The VA] had a major outburst after [s/he] was given cues to go to [his/her] room.” o R1 yelled at the VA, and R2 woke up. The VA “tried to swing a chair” at the SP after the SP moved the TV remotes. o P2 responded to the SP via text message and asked if thing were “okay now?” o The SP responded, “That shit was ridiculous,” and said the VA was “throwing threats at everyone.” · On September 23, 2023, at 1:54 p.m.: o The SP texted, “That wasn’t the first time, but it’ll be the last time [because] if need be [s/he] will be dragged to [his/her] room next time.” o The SP added the VA was “treated better” than the other individuals who lived at the facility, and that other staff persons “baby” the VA. P2 provided the following information: · P2 was not present for the incident, and the SP was the only staff person working at the time of the incident. The SP contacted P2 regarding the incident and LE responded to the facility. The SP told P2 that s/he was “protecting” him/herself when the VA attempted to hit him/her with a chair. P2 did not specify what the SP meant by “protecting” him/herself. · P2 spoke with R1 and R2, and they said the VA tried to hit the SP with a chair because the SP would not get out of the VA’s face, and the SP said “mean things” to the VA. Due to incident, the SP was suspended from working at the facility. · P2 contacted P1 regarding the concern, and P1 went to the facility, however LE had already arrived at the facility. · The VA had a “scruff mark” on his/her knee after the incident, but declined any medical care. · The VA moved into the facility a couple years prior to the incident and had never engaged in verbal or physical aggression before at the facility. · The SP wrote a report regarding the incident before LE arrived at the facility. Three “Occurrence/Injury Reports” were written by the SP for the VA, R1, and R2, which provided the following information: · The “Occurrence/Injury Report” for the VA stated that on September 22, 2023, at 10 p.m., the SP was playing a game with R1, and the VA was sleeping on the couch in the living room. The SP provided VA “verbal cues” to go to his/her bedroom, however the VA became “argumentative” with the SP. The VA threatened the SP and R1, “got angry” at the SP and tried to swing a metal folding chair at the SP. · The “Occurrence/Injury Report” for R1 stated R1 was playing a game with the SP, and the VA threatened bodily harm to R1. The SP noted R1 was “annoyed by previous incident” and R1 started rocking the couch. The VA pushed the couch backwards causing both the VA and R1 to fall to the floor. Neither R1 nor the VA were injured, however the VA continued to make threats towards the SP and R1. · The “Occurrence/Injury Report” for R2 stated R2 came upstairs from his/her bedroom and told the VA to stop acting “childish.” The VA “bum rushed” R2, and R2 almost put the VA in a hold, but the SP was able to get R2 and the VA to separate. R2 returned to his/her bedroom after the incident. The VA and R2 were not injured during the incident. The VA provided the following information: · The VA was sleeping on the couch, and the SP told the VA to go to bed. However, the VA told the SP, “No.” The VA said during the interaction the SP was not allowing the VA to watch television, told the VA s/he was “acting like a child,” and called the VA a “baby.” The VA said the interaction made him/her feel angry and sad. After that the VA said s/he grabbed a folding chair, but denied trying to hit the SP with the chair. The SP grabbed the chair out of the VA’s hands and took the chair and the VA’s bottle of juice to the kitchen. · While the SP was in the kitchen, R1 was “being a jerk” and pushed the couch that the VA was sitting on. The VA went to the kitchen and R2 blocked the VA from returning to the living room. R2 grabbed the VA by the throat and threw the VA to the kitchen floor, and the VA scraped his/her knee. The SP was outside smoking when R2 grabbed the VA. · The VA became emotional and cried because of the way the SP was treating him/her during the incident. · The SP had called the VA names in the past, but the VA was not able to provide any examples of what names s/he was previously called. P1 provided the following information: · P2 contacted P1 on the night of the alleged incident, and P1 went to the facility. P1 spoke with the VA, and P1 described the VA as “upset.” The VA told P1 that it was not “fair,” because the SP was trying to play a game, and the SP did not want the VA sitting in the living room. The VA continued to tell P1 that R1 threw the VA onto the floor, and R2 “choked” the VA during the incident. The VA added that the SP told R1 and R2 to do those things. P1 did not provide any information regarding the VA being called any names, and P1 believed the incident was related to the use of the television. · P1 observed the living room couch, which was across the room from where it normally was located, and R1 said s/he was rocking the couch with his/her knee trying to get the VA to wake up. P1 said R1’s statement did not match what s/he had observed with the position of the couch. · P1 spoke with R1 and R2 on September 24, 2023, and R2 asked P1 if the SP “Rolled on us.” P1 continued talking with R1 and R2, and P1 felt the SP had “orchestrated the whole thing,” in part because R1 and R2 said the SP was “bribing” R1 and R2 with items like shoes, and fighting lessons. P1 assisted R1 and R2 with writing a statement regarding the incident (see below section for additional information). P1 felt the information from R1 and R2 changed to “almost fit their need.” There was no other information obtained which showed the SP provided any fighting lessons to R1 or R2. · P1 was not aware of any prior issues between the SP and the VA. P3 provided the following information: · P3 was not present for the incident, but the SP sent P3 text messages about the incident, including a message stating the VA attempted to hit the SP with a chair. · P3 spoke with the VA regarding the incident and the VA said the SP called the VA a “big baby” and another name, possibly “dumb” or something similar, but P3 could not recall. P3 provided limited information related to what the VA told him/her about the interactions the SP had with the VA prior to the alleged name calling and the interactions between the VA and R1 and R2. · P3 also spoke with R1 and R2 regarding the incident, and P3 felt that based on the description of events from R1 and R2, that the SP was the “ringleader” of the incident. · R1 provided conflicting statements to P3 regarding R1’s and R2’s involvement in the alleged incident. R1 said the SP was loudly telling the VA to go to bed, and R1 went outside. After returning inside R1 observed a chair sliding across the floor, and the VA was on the floor. However, R1 later changed his/her account, and said s/he “blacked out” and “flipped” the VA off the couch after the SP had told R2 to “do it.” P3 believed R1 had caused the VA to fall off the couch. P3 said R1 told him/her the SP had bribed R2 with shoes, but later recanted the statement, and said s/he had asked the SP for shoes prior to the incident. P3 said R1 had a history of “storytelling,” and might tell “stupid little fibs,” but R1 did not lie about “serious things.” · P3 said R2 admitted to having physical contact with the VA, however R2’s statements related to the physical contact were different from those provided by the VA. R2 told P3 that s/he grabbed the VA around the waist and the VA “dropped” his/her body weight, whereas the VA stated R2 had choked him/her. R2 said the SP instructed R2 to block the VA from going back into the living room. · The VA had prior issues with sharing the television, but there was no history of similar incidents at the facility. P3 said there were previous incidents in which the VA had sworn at the SP, but there were no other known issues between the VA and the SP. The SP and R1 had previously engaged in power struggles, but R1 provided limited details regarding the interactions. P3 did not have information that other staff persons had witnessed any other incidents. R2 provided the following information: · R2 was in his/her bedroom when s/he heard two loud “thumps” from the living room. R2 was not sure what made the thumps, but was later told either the SP or R1 had “tipped” over the couch. R2 said s/he left his/her room and went to the living room, and observed the SP “taunting” the VA by getting in the VA’s way. The VA responded by grabbing a chair and attempted to hit the SP, but missed. The SP proceeded to grab the VA’s drink container, and moved it to the kitchen. The SP then asked R2 to block the VA from going back into the living room, and R2 stood in the way of the VA. R2 described grabbing the VA around the waist and “before” s/he knew it the VA dropped down, resulting in R2’s arms being around the VA’s neck/head area. · Initially R2 said s/he did not “recollect” the SP calling the VA any names during the incident, but later said the SP called the VA a “baby.” · R2 did not have any other concerns or issues with the SP. · R2 said after the incident “no one” wanted the SP around the facility. P1 wrote statements from R1 and R2 regarding the alleged incident which provided the following information: · R1 said the SP shouted “boo” at the VA to wake him/he up, proceeded to repeatedly tell the VA to go to his/her bedroom, and used swear words that were directed at the VA. The SP said s/he could not make the VA do anything, but insinuated that R1 would, and R1 rocked the couch until the VA fell to the floor. R1 said the SP screamed at the VA (no specific sentence or words were described by R1), and “aggressively” moved the couch cushions. The VA grabbed a folding chair, but the SP was able to get the folding chair and pushed the chair across the floor. During the incident with the chair, the VA was knocked to the floor and was crying. The SP then took the VA’s drink container, and the VA tried to get it back, however the SP yelled to not let the VA back into the living room. R2 responded by grabbing the VA and throwing the VA down by his/her neck. During the physical contact the SP stood and watched, before telling R2 to let the VA go. Later the VA attempted to apologize, but the SP said the VA was “pissing [him/her] off” and called the VA a “baby.” · R2 said s/he was awoken by two big bangs on the floor, and went upstairs. R2 observed the VA on the floor, the couch was moved, and the couch pillows were on the floor. R2 saw the SP in front of the VA “taunting” the VA, and the SP and VA were yelling back and forth at each other. The VA got a folding chair, but the SP was able to get it out of the VA’s hands, and slid the folding chair across the room. The SP then took the VA’s drink container into the kitchen and the VA followed the SP. The SP said, “Block [him/her],” and R2 grabbed the VA. R2 held onto the VA until the VA “dropped down,” and R2’s arm came to rest under the VA’s chin. The SP told R2 to let go of the VA, and added s/he said to block the VA “not to grab” the VA. The VA went to his/her bedroom, and the SP called the VA a “baby.” The SP told R1 and R2 that s/he made the “reports look like it was all” the VA. The SP provided the following information: · The SP attempted to describe the alleged incident, but said it was hard to explain as it all happened so fast. · When the incident began, the VA was in the living room sitting in a chair, the SP was sitting on a folding chair, and R1 was also in the living room. The SP verbally prompted the VA to go to bed as s/he was falling asleep in the chair while watching TV, however the VA got upset, started using “expletives,” and threatened to harm the SP and R1. R1 then “rocked” the chair the VA was sitting in. The VA “slid” to the floor and grabbed the folding chair the SP was previously sitting on. The VA then attempted to hit the SP with the folding chair, but the SP was able to get the folding chair from the VA. The SP said s/he was not sure why the VA tried to hit him/her with a chair, and the SP “escalated” his/her voice after the VA attempted to hit him/her with the folding chair, and moved the folding chair to a safe location. The SP also moved the VA’s drink container to the kitchen to prevent a mess from occurring. The VA went into the kitchen to get the drink container, and the SP told the VA to not go back into the living room. R2 (who had come out of his/her bedroom) was blocking the doorway to the living room and the VA moved towards R2. R2 put the VA in a “hold,” and the VA fell to the floor. The SP denied telling R2 to place the VA in a hold. After the incident the VA went to his/her bedroom, started throwing items, and continued to make threats towards the SP. The SP called LE before going outside where s/he waited for LE to arrive. · The SP denied taunting the VA, calling the VA names, instructing R1 to touch the chair the VA was sitting in, or instructing R2 to make physical contact with the VA or to block the VA from returning to the living room. · The SP denied engaging in any favoritism or coercion towards any of the vulnerable adults at the facility related to the incident. The SP said s/he had previously given R1 a pair of shoes as s/he needed a new pair of shoes, but it was not related to this incident. · The SP said the text messages s/he sent to P2 regarding the incident were meant as a joke, and s/he was trying to calm down after the incident. · The SP said the VA had engaged in three or four other incidents of verbal aggression towards the SP, but none of those incidents were as significant. P1, P2, P3, and the SP were each trained on Reporting of Maltreatment of Vulnerable Adults Act and the VA’s client specific programming. The SP’s job description stated staff persons should interact with vulnerable adults in a professional and caring manner. Staff persons were responsible for following all individual programs and approaches as outlined in individual plans, including the responsibility for the overall care and supervision of individuals, based on the individual’s client specific programming. Relevant Rules and/or Statutes: Minnesota Statutes section 245D.04, subdivision 3, paragraph (a), clause (6) states that a person’s protection related rights include the right to be treated with courtesy and respect. Conclusion: On September 22, 2023, an incident involving the SP, the VA, R1, and R2 occurred at the facility in which LE was contacted, however there was no further LE investigation. The interviews with the VA, the SP, R1, R2, P1, P2, and P3, included information that was consistent, however there was also opposing and conflicting statements from multiple persons, as well as information that was changed or recanted from R1 and R2. Additionally, there was inconsistent information related to the order of events. There was conflicting information related to whether the SP called the VA names. The VA, R1, and R2 each said during the incident the SP called the VA a “baby.” However, the SP denied calling the VA any names. Given the information obtained, the SP more likely than not engaged in behavior that was disrespectful and non-therapeutic during the incident. Although the VA said the SP had called him/her names in the past, the VA was unable to specify what names, and there was no other information which corroborated the SP engaging in name calling towards the VA during prior incidents. There was conflicting information related to the VA falling off of the couch in the living room. The VA said R1 moved the couch, however the VA did not make any comments that the SP instructed R1 to move the couch. R1 provided conflicting statements regarding his/her involvement in the incident. The SP denied instructing R1 to move the couch. Based on the information it was more likely than not R1 moved the couch resulting in the VA falling to the floor, but the SP’s role in this activity was unclear. There was some information the SP told R2 to block the VA from entering the living room after the incident, as the SP did not want the VA to return to the living room. R2 blocked the doorway, and the VA and R2 had physical contact which resulted in R2 holding the VA’s head/neck. The physical contact ended when the SP told R2 to let go of the VA. Although the SP denied telling R2 to block the VA from returning to the living room, all other information showed the SP did not want the VA to go back into the living room. However, due to conflicting information, the SP’s role in this activity was also unclear. During the course of the incident the SP’s actions were disrespectful, were inconsistent with the role of a professional caregiver in a facility licensed by the Department of Human Services, and were in violation of Minnesota Statutes section 245D.04, subdivision 3, paragraph (a), clause (6). However, based on the information obtained there was not a preponderance of the evidence as to whether the SP's conduct of name calling was repeated. Additionally, there was not a preponderance of the evidence as to whether or not the SP instructed R1 and R2 to engage in actions which endangered the VA’s physical or emotional safety. It was not determined whether emotional abuse or neglect occurred (conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening; the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). Action Taken by Facility: The facility completed an internal review and determined the facility’s policies and procedures were adequate, but not followed. The alleged incident was not similar to past events. The facility provided all staff persons with additional training on Person Centered Services and Positive Supports. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: Given that the facility took immediate corrective action to address the violations outlined in this report, a Correction Order was not issued. No further action was taken.
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